Medicaid expansion under ACA appears to improve cancer clinical trial access
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CHICAGO — The Affordable Care Act’s expansion of Medicaid resulted in a nearly threefold increase in the percentage of patients using Medicaid in cancer trials by early 2020, according to study results presented during ASCO Annual Meeting.
The newly enacted Cancer Treatment Act, which mandates that state and Medicaid programs cover routine care costs of clinical trial participation, could further improve access to clinical trials for individuals with Medicaid, researchers noted.
Rationale and methods
“Our study was motivated by the recognition that the Affordable Care Act Medicaid expansion has broadened access to insurance for socioeconomically vulnerable populations. In light of this, one key question is whether increased access to Medicaid insurance has improved access to clinical trials for patients with cancer,” Joseph M. Unger, PhD, SWOG Cancer Research Network health services researcher and biostatistician at Fred Hutchinson Cancer Research Center, told Healio.
Unger and colleagues used SWOG Cancer Research Network data to examine the number and proportion of patients with Medicaid at enrollment throughout time. The study included 47,042 patients aged 18 to 64 years (67.1% women; 40.4% aged < 50 years; 10% with Medicaid) enrolled on trials between April 1, 1992, and Feb. 28, 2020, who had either Medicaid or private insurance. The researchers performed an interrupted time-series analysis, including the first implementation of ACA Medicaid expansion as an independent exposure variable. They then used segmented logistic regression to estimate the difference between actual clinical trial enrollment of patients using Medicaid to the expected rate if ACA Medicaid expansion had not been implemented. They adjusted for the monthly unemployment rate, per the Bureau of Labor Statistics, to account for secular trends associated with economic conditions.
Key findings
Results showed a 20% (OR = 1.2; 95% CI, 1.11-1.3) overall increase per year in the odds of patients using Medicaid included in cancer clinical trials after implementation of ACA Medicaid expansion.
The proportion of patients who utilized Medicaid in a clinical trial decreased during periods of economic growth and low unemployment before implementation of ACA. According to a model-based estimate, had ACA Medicaid expansion not occurred, the proportion of patients with Medicaid insurance would have been 7.4% (95% CI, 4.8-9.5) at the end of the study in February 2020, when the national unemployment rate was 3.5%. The actual rate was 20.8% (95% CI, 17.1 to 25).
Researchers observed consistent patterns in Medicaid use by age but not by sex, with a 29% (OR = 1.29; 95% CI, 1.17-1.42) annual increase in the proportion of Medicaid use among women vs. 7% (OR = 1.07; 95% CI, 0.94-1.23) among men.
Compared with an only 7% (OR = 1.07; 95% CI, 0.94-1.22) increase per year in Medicaid use among patients residing in states that did not implement the expansion in 2014 or 2015, those who resided in states that did implement expansion increased use 27% (OR = 1.27; 95% CI, 1.16-1.41) per year.
Looking ahead
“These findings are important because clinical trials are vital for determining whether new experimental treatments should be adopted into routine community practice as new standard care,” Unger said. “Thus, understanding what types of patients participate in trials and whether this change with the advent of the ACA Medicaid expansion is important for interpreting trial results. We next plan to examine whether outcomes in clinical trial patients differ according to their type of insurance.”
For more information:
Joseph M. Unger, PhD, can be reached at Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N, M3-C102, Seattle, WA 98109; email: junger@fredhutch.org.
Perspective
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ACA has expanded access to health care, a fundamental human right. This expansion also means increased access to cancer treatment. Clinical trials are the gold standard for cancer treatment, helping to improve cancer care for today and for the future.
This study showed that Medicaid expansion as part of ACA has increased access and enrollment into clinical trials by 20%, which is an important finding. Disparities in access and enrollment to clinical trials is a major challenge faced at cancer centers across the country. One of the major barriers to access to clinical trials is health care coverage. Medicaid expansion under ACA has successfully demonstrated that we can break down some of those barriers.
Current clinical trial enrollment in the US is about 5% to 7%, but the rate is lower among people with no health insurance. Clinical trial accrual among the minority community is even lower. We need to continue to work to improve access and enrollment on clinical trials. I applaud SWOG for leading this important study.
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Unger J, et al. Abstract 6505. Presented at: ASCO Annual Meeting; June 3-7, 2022; Chicago.
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